Tuesday, April 28, 2009

Swine Flu and Infection Risk

The emergence of a new influenza virus has created a frenzy of misinformation and panic. TV news shows people wearing paper face mask, the latest signal that the world is a dangerous place. While I have broadcast my concern for many years that infection surveillance is inadequate and promoted a new ethic of social responsibility, I find the frantic media reports this week to be offensive if not absurd. Social responsibility means -- don't spread infections you have acquired; if you are sick, stay at home.

There are real dangers in the world. Infectious agents evolve continuously. Increasing populations and increasing urban density are ideal for infection transmission. Transportation of people and goods all over the world means that infections become worldwide in a matter of days, not localized. I continue to meet physicians who think they are living in the nineteeth century and refer to localized, "endemic" infection.

Solutions can only be found by well-informed, calm methodical people. Turn off CNN and let us proceed with caution and appropriate concern. In my business, we have looked at air quality issues for several decades. Here is a response to a typical question we addressed:

Question: I do a lot of international flying, from North American to Asia, several times a month. I have gotten, many times, upper respiratory infections, bronchitis, bad coughs that my physicians, as well as my common sense, tells me comes a great deal from the poor air quality on airplanes. In addition, just the past week, with the outburst of some kind of Asian virus with serious symptoms, I want to protect myself as much as possible, while at least on the airplanes. What masks do you suggest, and any other comments or suggestions you might have?

Answer: We have looked at this problem repeatedly over 2 decades and not arrived at a satisfactory method of personal protection except for canceling the flight. You have to accept that traveling involves exposure to thousands of strangers who may infect you with microbes most of which, you have not encountered before and you will lack protective immunity. This increased exposure begins when you leave home and continues even after you arrive back.

You have to disinfect everything, including yourself, before you are free of foreign microbes. It’s easy to focus on the in-flight conditions, but exposure in the aircraft is only a small component of the overall risk of infection when you travel. Biological agents infect through the respiratory mucosa; ingestion; contact with the mucous membranes of the eyes, or nasal tissues; by penetration of the skin through scratches, small cuts and abrasions Organic airborne particles share the same characteristics in air or on surfaces as inorganic particles from hazardous dusts.

Here is a quick summary of the basic strategies you can use:

Disposable paper face masks provide minimal protection against dusts, fungal spores and bacteria, but not viruses. These are obviously the cheapest, most available and probably most acceptable to wear in public including in airports and perhaps on a flight. The protection rating is hard to assess, but is probably very low in the range of 5-10. Paper masks with a NIOSH protection rating of 100 offer better protection against viruses, if you wear them properly.

The mask has to be changed often and you must wash your hands after handling the mask. For more serious protection you can use half-mask or full-face air-purifying respirators with particulate filter efficiencies ranging from N95 (for hazards such as pulmonary tuberculosis) to P100 (for hazards such as viruses). The protection rating is somewhere between 50-200, depending on the filter chosen and degree of proper utilization.

The best protection against airborne infectious agents (as well as all airborne toxins) is provided by self-contained breathing apparatus (SCBA) respirators with a full facepiece operated in a positive pressure mode. This reduces the hazard from most sources -- airborne particles, microbes, chemical vapors and gases. The National Institute for Occupational Safety and Health (NIOSH) suggests that the proper use of SCBA reduces the user’s exposure by at least 10,000.

Decontamination of clothing is a precaution against particles that have settled on the outside. Use detergent, hot water, and 0.5% hypochlorite solution (one part household bleach to 10 parts water) to wash clothes and baggage. You should wash your hands frequently and shower ASAP after a flight using generous quantities of detergent and water. Shampoos contain detergents that tend to be better cleansers than regular soap. Use a basic shampoo as a whole body wash.

Until more people wear APRs and everyone is used to them, we can assume that if you strap one on to go to work, travel in an airplane or walk the dog, most people will think " you look weird!" We are not sure how new security regulations will treat the use of APRs on airplanes… it will controversial.

See the book, Air and Breathing by Stephen Gislason MD

Sunday, April 26, 2009

Unsafe? Avandia for Diabetics

There have been a succession of disappointments about drug therapy in recent years. One drug, Avandia, became a popular diabetes medication. It took several years and a brave MD to uncover evidence that it is not such a good drug, after all.

Avandia is rosiglitazone, a popular diabetes 2 drug. Doubts were raised about the safety of this drug and there are arguments for and against it. The arguments and concerns will not be resolved quickly. Avandia is marketed by Glaxo, which, like all drug companies, vigorously defends its big money drugs. Sales of Avandia reached $3.2billion per year in the US.

Our perspective for 2 decades is that the drug treatment of diabetes lacked convincing long-term efficacy and there were important concerns about side effects and long-term adverse effects. Oral medications should not be considered as primary treatment. However, MDs tend to be drug prescribers, drug companies are interested in making money and patients are obedient consumers who like to believe there are simple solutions for complex problems.

Dr. Steven Nissen and colleagues from the Cleveland Clinic reviewed more than 40 studies and concluded that Avandia increased the risk of heart attacks by 43 percent. Psaty and Furberg recalculated Nissen’s analysis using interim results of the Record study in addition to the studies that Nissen used. They found that Avandia increased a patient’s risk of having a heart attack 33 percent. Nissen is an experienced but independent FDA advisor who has become an ombudsman for the American people.

In the US where Avandia was developed and concerns were announced, questions about the safety of Avandia and how regulators have dealt with its risks were asked at Congressional hearing in June 2007. Glaxo had an ongoing study, REPORT, and rushed to submit favorable interim results for publication in advance of the government hearing.

In his New England Journal editorial, Dr. David M. Nathan, a Harvard diabetes expert, doubted the value of the REPORT study because of the high number of patients who dropped out and the study design which compared Avandia to a combination of metformin and sulfonylurea. While this combination is popular, doubts about its safety were raised and never resolved in another study that showed a 96 percent increase in diabetes-related mortality. Metformin alone appears to be relatively free of cardiovascular risk. Nathan concluded that the interim results of the Record trial do not provide any assurance of the safety of treatment with rosiglitazone and suggested that doctors should use medications other than Avandia.

A series of drug adverse effect withdrawals in recently years have generated criticism, that the US Food and Drug Administration fails to protect the public. In the Avandia case, critics say that the US FDA should have warned about the potential heart risks years ago. A supervisor in the drug safety office at the agency said in an interview that she was rebuked after calling for a stronger warning label on Avandia and a competing drug, Actos.

November 20, 2007: A US Senate Committee on Finance released a report describing what it terms the "intimidation" of Dr John Buse by GlaxoSmithKline (GSK) over his concerns about the cardiovascular risks associated with the company's antidiabetes drug rosiglitazone (Avandia). The committee stated: "According to documents provided to the committee by, among others, GSK and the University of North Carolina, it is apparent that the original allegations regarding Dr Buse and GSK’s attempts at silencing him are true. According to relevant emails, GSK executives labeled Dr Buse a 'renegade' and silenced his concerns about Avandia by complaining to his superiors and threatening a lawsuit."

The main problem for a growing number of patients is the false belief that a drug or combination of drugs can rescue an individual from a disease-causing lifestyle. While there may be benefits to be had with medications, a person with diabetes 2 should learn expert self-management skills and exercise all the therapeutic and preventative options available before taking drugs.

From the Book Managing Diabetes 2 by Stephen Gislason MD

See further discussions of medical biases and limitations

Also See Diabetes Drugs

Monday, April 20, 2009


While the term “healthcare” is popular, it misrepresents health in every possible way. Health is supposed to refer to being “healthy” – free of disease, physically fit, productive and happy. Healthy people do not need to spend money on doctor visits, drugs, hospitals and surgery.
So what is a more accurate term than healthcare? Medicalcare is the proper term. Medicalcare is a heterogeneous collection of products and services provided by MDs, drug suppliers and hospitals that deal with people who are not healthy. Sometimes medical intervention is merciful, humane and lifesaving. Most of the time, medical care is wasteful, inefficient and potentially dangerous. Healthy people do not seek medical care.

Lundberg, Editor of MedGenMed stated that: “The US medicalcare system is immensely complicated, almost inexplicable, costly beyond belief, seriously discriminatory, and often unsafe. The money expended from all sources in American medicalcare is extraordinarily large, some $1.7 trillion in 2004, one seventh of the total US economy, and larger than the total economies of most countries of the world.” Lundberg suggests that the marketplace" determines how much money is spent on what and how many people of what types work in medicalcare but it is not a free market. “

People in the US and Canada are less than healthy because they eat too much of the wrong food and exercise too little. The mechanisms of bad-food diseases are numerous and complex. Profit can be made by attempting to manage the consequences of eating too much and exercising too little. Marketing chemicals to reduce the negative effects of eating too much of the wrong food is unbelievably profitable, even though none of the drugs are really required. Canada is the third-highest-per-capita spender on drugs among industrial countries after the United States and France. Canada spent $3,003 US per person in 2003 lower than the U.S. at $5,635. Norway and Switzerland were next in line at $3,800 per capita. All affluent countries are spending more on drugs, increasing 32 per cent between 1998 and 2003 to more than $450 billion annually. Growth in spending on pharmaceuticals outpaced the rise in total health-care expenditures in most countries, including Canada. In the U.S. and Australia, spending on drugs grew more than twice as fast as total health expenditures.

The real solution is not taking drugs, but removing the causes of disease, by, for example, eating less, choosing the right foods and exercising more.

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Wednesday, April 15, 2009


For many years, I collected reports from patients disappointed in the medical care they received. For several years patients would come into my office and complain that they had seen several doctors, had many investigations and tried many drugs without benefit. I noted that patients routinely left the care of their physicians and shopped around the “alternative” community and bought curious, bizarre and often expensive tests, treatments and products with little hope of benefit.

I am aware of the limitations of physicians, however, and want my well-educated, well-motivated reader to recognize these limitations and assume responsibility for their own management. When you look critically at modern medicine you see expensive techniques deployed to rescue individuals from calamities which were often avoidable. Although many talk about the "health-care system", they are really talking about a high-cost medical intervention system, directed at treating diseases that are fully developed, but not preventing disease. While “high tech” medicine promises miraculous cures, there only is a short list of problems which can be fixed by medical or surgical methods but a much longer list of problems which cannot be fixed.

One problem is that MDs seldom learn how to manage food-related diseases. In the physician’s mind, food is someone else’s responsibility. Physicians, like everyone else, have prejudices and preconceptions that limit their understanding of the complex issues that determine food selection, metabolism and the consequences of bad diets. Both physicians and patients have an overwhelming bias in favor of drug and surgical treatments. Medical practice is based on a routine of ordering tests and writing prescriptions for drugs.

While diet and “life-style” modifications are mentioned in medical texts, few MDs pursue this approach to patient management. Many MDs have argued that the task of changing patients’ habits is beyond their mandate, is too time-consuming, and is often futile. Even if MDs are interested in solving food-related problems, they are usually too rushed to spend the time necessary teach patients the knowledge and skills they require to self-manage effectively.

There is a fundamental misunderstanding between doctors who know something about their limitations and patients who often have unrealistic expectations for fast solutions. Both sides of the relationship become frustrated and tend to act irrationally when quick and easy solutions do not work. The more passive and dependent a patient is, the deeper this misunderstanding grows and the more expensive it becomes. Patients demand more investigations, referrals, and support services. Physicians tend to order more tests and prescribe more drugs and that are increasingly potent and more risky. When neither strategy works, many illnesses remain unsolved, suffering is not relieved and expensive problems continue to drain the resource of individuals and their communities. Stephen Gislason MD

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